COMPLIANCE INFO_1985-1996 - Laserfiche WebLink

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" " INSI'RUC:ITONS M C OMPI:If,'17NCi FORM 14 GENERAL LNStRUC11ONS- 1. One FORM"B"'shall•be completed for cash tank:for all NI,7,W PERM,1`TS,PERMrl'C'11ANGES, REMOVALS and/or any other"TANK INFORMA'ITON CHANGE, 2. This form should be completed by either the ?iia I1`APPY,14°1" l'far the 1,()C:AI.AGENCY UNDERGROUND TANK INSPEC71'OR. 3. Please type or print clearly all requested information. 4. Use a hard,point writ;+ng instrument,you are making 3 copies. TOP OF DORM: "MARK ONLY ONE TIT..M" 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed, 2. Indicate the DM,\or facility name wher;u the tank isinstalled, I. TANK DENCRIPI7ON-C OMPLEIT3 A1.1.rMIMS--Il''UNKNOWN-SO SPECIFY A. Indicate owners tank ID # -If there is a tank number that is used by the owner to identify the tank(ex.AB70789). B. Indicate the name of the company that manufactured the tank (c.x.ACMETANK MFG,). C. Indicate the year the tank was installed (ex. 1987). D. Indicate the tank capacity in gallons (ex. 25,000 or 10,000 etc.). 11. 'TANK CONFENI.S A. 1. If MOTOR VEHICLE FUEL,,check box 1 and complete items B 8;, C. 2. If.not MOTOR VEHICLE' FUEL„check the appropriate box in section A and complete items B& D, B. Check the appropriate box. C. Check the type of MOTOR VVIIIC LE FUEL(if box 1 is checked in A). L). Print the chemical name of ehc hazardous substance stored in the tank and the C;,A,S.#. (Chemical Abstract Service number), if box I is NOT checked in A. Ill. 'TANK CONS17tUCI'ION-MARK ONE ITEM ONLY IN BOX A,B,C&D 1, Check only one item in TYPE OF SYSI'T4,M,TANK MATERIAL, INTERIOR LINING and CORROSION PRO'IT:CTION. 2. If OTLIEI2, print in the space provided. IV. PIPING INFORMATION 1. Circle A if above ground; circle U if underground; and circle both if applicable. 2. If UNKNOWN,circle; or if 01LIIIR,print in space provided. 3. Indicate the LEAK DI T'EC:''ION system(s)used to comply with the monitoring requirement for the piping. V. 'TANK LEAK DINIX711ON 1. Indicate the LEAK DENI3CTION system(s) used to comply with the monitoring requirements for the tank. VT. INFORMNI`lON ON TANK PERMANINIL Y 0A)SUD IN PLACE, 1. I'i'STIMA"I'T D DAIIlii [AS'['USED-MONT'II/YEAR (January, 1988 or 01/88). 2. I "IMATEI7 QUANI'I"TY of IIA/ARDOUS SULTSTANCL;remaining in the tank (in Gallons). 3. WAS TANK FILLED WITII INI'.RT'MNI'El'UAL? Check 'Yes'or'NO'. APPLIC:ANI'MUST SIGN AND DA'IT?17113 FORM AS INDI(W110. IN:ti:I'RUCI'ION FOR'11113 LOCAL AGENCII:?S The state underground storage tank identification number is composed of the two digit county number, the three digit jurisdiction number, the six digit facility number and the six digit tank number. The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2421. The facility number must be the same as shown in form "A". The tank number may be assigned by the local agency; however, this number must be numerical and cannot contain an alphabet. If the local agency prefers the State Board to assign the tank number, please leave it blank. rI'IS TTIE RESPONSIBILITY OF 113E I.QCAL AGENC` THATINSPEC715'11113 FACILTI'Y TO VERIFY 11173 ACCURACY OF'I1IE INFORMA170N. THE LOCAL AGENCY IS RIiSPONSIBLE FOR 311E COMPI.XUION OF THE *LOC:AL AGENCY USI?ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND AS,SOCINIED FORM"B'(s)1101111.1 FOI.I.OW[NG ADDRESS. STAT1:?OF C.AL.I]PORNIA STAIE WAI13R RESOURCES C,'ON 'ROL BOARD C/O&W.1 F.P.S. DATA PROCI3 TNG C:ENII3R P.O.BOX 527 PARAMOUNI',CA 9(X723